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Venous Thromboembolism (VTE)

June 2018

This Clinical Practice Model (CPM) is designed for patients:

Adults over the age of 18

With suspected lower extremity deep venous thrombosis (DVT) or pulmonary

embolism (PE), not associated with cancer

Being seen in a PHS hospital, emergency department, urgent care, and/or PMG

primary care clinic

This CPM is based on recommendations from Presbyterian’s evidence-based care design

(EBCD) initiative for VTE and the Anticoagulation Subcommittee. It offers Providers

guidance for the evaluation and management of patients with suspected DVT or PE, to

expedite diagnosis and potentially improve treatment outcomes.

Why Focus on VTE?

Each year in the United States, as many as 900,000 people could be affected (1 to 2 per

1,000) by DVT/PE, and an estimated 60,000-100,000 Americans die of DVT/PE. Among

people who have had a DVT, one-half will have long-term complications (post-thrombotic

syndrome) such as swelling, pain, discoloration, and scaling in the affected limb. One-third

(about 33%) of people with DVT/PE will have a recurrence within 10 years. Up to 60% of

VTE cases worldwide occur during or after hospitalization. VTE contributes significant

morbidity and mortality both in the community and in hospital. Given the risks associated

with untreated lower extremity DVT (e.g., fatal pulmonary emboli) and the risk of

anticoagulation (e.g., life-threatening bleeding), accurate diagnosis of DVT is essential. The

clinical presentation of PE is variable and often nonspecific, making the diagnosis

challenging.

Care Pathway Roles and Responsibilities

Responsibility Clinician

Receives phone calls or warm handoff regarding patient with urgent symptoms

Nurse Care Manager (RNCM)

Prepares patient; obtains vitals; performs medication reconciliation

Primary Support MA/LPN

Clinical assessment; diagnosis; initiate treatment Provider

D-dimer testing TriCore Technician

Doppler testing Ultrasound Technician

Manages anticoagulated patients and anticoagulation education

Nurse Care Manager (RNCM) or Pharmacist Clinician

Administers interventions such as thrombolytic therapy, clot removal, or IVC filter placement

Intensivist or Interventional Radiology

Schedules appointments for patients requiring anticoagulation services

Patient Navigator

Makes a follow up phone call within 24 hours after discharge

Discharge Call Center Nurse

This CPM presents a model of care based on scientific evidence available at the time of publication. It is not a prescription for every physician or every patient, nor does it replace clinical judgment. All statements, protocols, and recommendations herein are viewed as transitory and iterative.

Although physicians are encouraged to follow the CPM to help focus on and measure quality, deviations are a means for discovering improvements in patient care and expanding the knowledge base.

If you have questions or concerns regarding this information, contact:

Clinical Leaders

Darren M. Shafer, DO dshafer@phs.org

Dion E. Gallant, MD dgallant@phs.org

Linda R. Kelly, PharmD lkelly@phs.org

This CPM is part of Presbyterian’s Clinical Care Model, a broad, enterprise-wide body of documentation covering PHS’ functions, programs, and care pathways, intended to build organizational acumen, facilitate cross-system collaboration, and accelerate our implementation of clinical initiatives.

Find all of PHS’ Care Model at www.PHSCareModel.org.

jump to ALGORITHM

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DVT: Assessment

Patient presents with symptoms of DVT

Consider D-dimer test

Provider assesses patient according to Wells Criteria

Consider another diagnosis

Provider ordersduplex Doppler

Wells Score for DVT(see page 3)

≤ 1

DVT unlikely

D-dimer

≥ 2

DVT likely

TriCoreTechnician

draws blood for D-dimer test

Patient monitors symptoms

Negative

Provider ordersD-dimer

Fast Result Lab Draw

Contracted vascular ultrasound Technician

administers onsite test

Positive

Doppler

Provider initiates appropriate orders

Negative

Positive

Provider manages care

Patient seeks medical attention if symptoms do not resolve or

worsen

❶

❷

❹

Provider advises Patientthat DVT is unlikely

Go to TREATMENT algorithm

(page 6)

❸

Care Pathway Notes:

❶ In a PMG Primary Care Clinic, the RN Care Manager schedules a same-day appointment with the PCP; if after 2:00pm, the patient is directed to Urgent Care. The Primary Support MA/LPN prepares patient according to guidelines for severe onset of calf/leg pain.

❷ Wells Criteria for evaluating DVT and PE are available as a Flowsheet in Epic.

❸ Most primary care and urgent care clinics offer onsite Doppler testing up until 3:00 pm. After that, the patient may be scheduled for testing within 24 hours at the diagnostic ultrasound office (High Desert Doppler), at PHG, or the ED.

❹ Epic support tools contain the current recommended orders for diagnosing and treating

DVT.

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DVT Diagnosis and Testing

Wells Scoring

The Wells Score can be used to estimate a clinical pre-test probability for DVT, for clinical decision support.

Pretest probability for DVT SCORE

WE

LL

S C

RIT

ER

IA

Active cancer (treatment ongoing or within the previous six months or palliative) 1

Paralysis, paresis, or recent plaster immobilization of the lower extremities 1

Recently bedridden for more than three days or major surgery, within four weeks 1

Localized tenderness along the distribution of the deep venous system 1

Entire leg swollen 1

Calf swelling by more than 3 cm when compared to the asymptomatic leg (measured below tibial tuberosity) 1

Pitting edema (greater in the symptomatic leg) 1

Collateral superficial veins (non-varicose) 1

Alternative diagnosis as likely or more likely than that of deep venous thrombosis -2

PR

OB

AB

ILIT

Y High ≥3

Moderate 1 or 2

Low ≤0

Modified Wells Criteria: a previously documented deep vein thrombosis (DVT) is given the score of 1. Using this modified model, DVT clinical probability is simplified:

DVT likely ≥2

DVT unlikely ≤1

For patients in whom a DVT is suspected, the recommended diagnostic approach incorporates clinical assessment with estimation of

pretest probability using the Wells score, D-dimer measurement, and, when necessary, ultrasonography with Doppler of the lower

extremities. Algorithm is shown on page 2.

The differential diagnosis in patients with suspected DVT includes muscle strain/tear, lymphedema, venous valvular insufficiency, popliteal

(Baker's) cyst, and cellulitis. There are no pathognomic clinical features that reliably distinguish DVT from competing diagnoses since

redness, swelling, tenderness, and pain are common to many of these disorders.

Risk Factors for VTE

Age >40

Family History of DVT/PE

Prior History of DVT/PE

Leg Swelling, ulcers, stasis, varicose

veins

Central line

Confinement/immobile >24h

Pregnancy, postpartum (6 weeks)

Myeloproliferative Disorder

Malignancy

Acute Respiratory Failure or COPD

Nephrotic Syndrome

Inherited Thrombophilia

Acquired Thrombophilia

Hyperviscosity syndromes

Obesity (>20% over IBW)

Acute MI/CHF

Estrogen Therapy

Severe sepsis (>1 organ system

failure)

Stroke with paresis

Spinal Cord injury with paresis

Multiple Trauma

Inflammatory Bowel Disease

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PE: Assessment

To rule out PE, patient must meet all criteria:

Age <50 Heart rate <100 bpm Oxyhemogobin saturation ≥95% No hemoptysis No estrogen use No prior DVT or PE No unilateral leg swelling No surgery/trauma requiring

hospitalization within 4 weeks prior

Patient presents with symptoms of PE

Provider considersD-dimer test

Provider assesses patient according to Wells Criteria

Consider another diagnosis

Provider ordersCTPA

Wells Score for PE(see page 5)

≤ 4PE unlikely

D-dimer

> 4PE likely

TriCoreTechnician

draws blood for D-dimer test

Provider manages care

Negative

Provider ordersD-dimer

Fast Result Lab Draw

Positive

CTPA

Provider initiates appropriate orders

Negative

Positive

Provider manages care

❶

❷

❹

Provider advises Patientthat PE is unlikely

Go to TREATMENT algorithm

(page 7)

❸

PERC criteria

rule out cannotrule out

< 2low

Care Pathway Notes:

❶ For hemodynamically unstable patients, see PE treatment algorithm, page 7.

❷ Wells Criteria for evaluating DVT and PE are available as a Flowsheet in Epic.

❸ For patients with a low clinical probability of PE (Wells score <2), PERC rule may be applied.

❹ Epic support tools contain the current recommended orders for diagnosing and treating PE.

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PE Diagnosis and Testing

Wells Scoring

The Wells Score can be used to estimate a clinical pre-test probability for PE, for clinical decision support.

Pretest probability for PE SCORE

WE

LL

S C

RIT

ER

IA Clinical symptoms of DVT (leg swelling, pain with palpation) 3

Other diagnosis less likely than pulmonary embolism 3

Heart rate >100 1.5

Immobilization (≥3 days) or surgery in the previous four weeks 1.5

Previous DVT/PE 1.5

Hemoptysis 1

Malignancy 1

PR

OB

AB

ILIT

Y High >6.0

Moderate 2.0 to 6.0

Low <2.0

Simplified clinical probability assessment (Modified Wells criteria):

PE likely >4.0

PE unlikely ≤4.0

For patients with suspected PE who are hemodynamically stable, the recommended diagnostic approach incorporates clinical assessment

with estimation of pretest probability using the Wells score, D-dimer measurement, and, when necessary, imaging (ultrasonography with

Doppler and/or CTPA). Algorithm is shown on page 4.

The differential diagnosis of PE includes many other entities that present similarly with dyspnea, chest pain, hypoxemia, leg pain and

swelling, tachycardia, syncope, and shock. Other competing diagnoses including heart failure, myocardial ischemia, pneumothorax,

pneumonia, and pericarditis may be distinguished on electrocardiographic, echocardiographic, laboratory, and chest radiographic testing.

However, PE can coexist with these conditions, and, therefore, the presence of an alternate diagnosis does not completely exclude the

diagnosis of PE.

PERC Rule

In patients with a low clinical probability of PE (Wells score <2), the pulmonary embolism rule-out criteria (PERC) may be applied:

Age <50 years

Heart rate <100 bpm

Oxyhemoglobin saturation ≥95%

No hemoptysis

No estrogen use

No prior DVT or PE

No unilateral leg swelling

No surgery/trauma requiring hospitalization within the prior four weeks

Patients who fulfill all eight criteria do not need additional testing. For patients who do not meet PERC or in whom PERC cannot be applied

(e.g., critically-ill patients), further testing with sensitive D-dimer and/or imaging should be considered.

Computed tomographic pulmonary angiography (CTPA)

For most patients with suspected PE, CTPA is the first-choice diagnostic imaging modality because it is sensitive and specific for the

diagnosis of PE, especially when incorporated in to diagnostic algorithms, and alternate diagnoses may be discovered using this modality.

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Lower Extremity DVT: Treatment

Consider thromboembolytics and/or thromboectomy

Isolated Distal DVT

AnticoagulationSurveillance

Continued surveillance

IVC Filter

Provoked, Unprovoked?

Unprovoked proximal DVT(no identifiable cause)

ORRecurrent DVT

ORProvoked with minor,

persistent, irreversible, or multiple risk factors

Stop anticoagulation

Consider indefinite anticoagulation

❶

❷

❸ ❹

❺

❼❻

Proximal DVT

Contraindication to anticoagulation?

Contraindication to anticoagulation?

Contraindication to anticoagulation?

Asymptomatic Symptomatic

No anticoagulation

Provoked DVT with major transient risk factor(DVT that is provoked

by a known event with an identifiable risk factor)

Phlegmasia cerulea dolens (PCD)?

Extension or at risk for extension?

YES

New extension?

NO

Stable

NO

YES

NO NO

NO

YES

YES

Contraindication resolved?

YES

NO

YES

DVT

YES

❶ Contraindications for anticoagulation include: high risk for bleeding; platelet count <50,000/mL; active hemorrhage; prior intracerebral hemorrhage. ❷ Risk factors for extension include: D-dimer is markedly positive (>500 mg/mL) without alternative reason; thrombosis is extensive (>5 cm in length, >7 mm diameter; involves multiple veins); thrombosis is close to proximal veins; no reversible provoking factor for DVT; persistent/irreversible risk factors such as active cancer; history of VTE; prolonged immobility; inpatient status.

❸ Follow up ultrasound of deep veins (e.g., every week for 2 weeks)

❹ Refer patient to Anticoagulation Clinic RN/Pharm Clinician; in Epic select REF111. See CPM: Choosing an Anticoagulant. ❺ Consider removal of IVC filter, if the contraindication is resolved. ❻ For patients in whom clot does not resolve but remains stable, longer periods of surveillance may be required. ❼ Stop anticoagulation after 3 months if provoking factor is resolved.

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PE: Treatment

Stop anticoagulation; administer

thromboembolytic agent; resume anticoagulation

Anticoagulation

No further evaluation

IVC Filter

❶

❹

❺

❻

❼

Contraindication to anticoagulation?

YES Unstable

PE suspected

NOYES

Diagnostic evaluation

PE confirmed

PE

Hemodynamically stable?

Wells Score for PE(see page 5)

PE likely

Will diagnostic evaluation take longer

than 24 hours?

PE unlikely

YES

No anticoagulation

NO

Diagnostic evaluation

Stop anticoagulation; consider other causes of

symptoms

PE excluded PE confirmed

PE

Does clinical severity warrant thrombolysis?

Contraindication to thrombolytic therapy?

Clinical improvement?

Surgical or catheter embolectomy

Continue anticoagulation

YES

Initiate/continue anticoagulation

YESNO

NO

PE excluded

YES

NO

NO

Evidence of right ventricle overload?

Hemodynamically stable?

Portable perfusion scanning or transthoracic

echocardiography

Resuscitation

Search for other causes of hemodynamic instability

NOYES

YES❷

❹

❸

❶ Hemodynamically unstable PE (“massive” PE) is that which presents with hypotension (a systolic blood pressure <90 mmHg for a period >15 minutes), hypotension requiring vasopressors, or clear evidence of shock.

❷ Contraindications for anticoagulation include: high risk for bleeding; platelet count <50,000/mL; active hemorrhage; prior intracerebral hemorrhage.

❸ Consider removal of IVC filter, if the contraindication is resolved. ❹ See CPM: Choosing an Anticoagulant.

❺ For most patients with hemodynamically stable PE, thrombolytic therapy is not recommended. However, in rare circumstances, thrombolysis may be considered on a case-by-case basis. ❻ Resuscitation involves any combination of respiratory (oxygen, noninvasive or invasive mechanical ventilation) and hemodynamic support (intravenous fluids, vasopressors). ❼ If transferring the patient to radiology for a CTPA is considered unsafe, alternative tests may help the Provider make a presumptive diagnosis of PE and guide management.

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Intervention (Acute)

Acute Deep Vein Thrombosis

Anticoagulation is indicated for most patients with acute lower extremity DVT. For select patients with isolated distal DVT (e.g., those at

high risk of bleeding, low D-dimer level, asymptomatic or minor symptoms, without risk factors for extension, and/or minor thrombosis of

the muscular veins), surveillance with serial ultrasound over a two-week period rather than anticoagulation is recommended. Those who

exhibit signs of thrombus extension should be anticoagulated.

For most patients with acute symptomatic proximal DVT, anticoagulation is recommended, unless the risk of bleeding is high. Similarly,

anticoagulation is recommended for patients with asymptomatic proximal DVT. (See treatment algorithm, page 6.)

In most patients, anticoagulation should be started immediately; delay in therapy may increase the risk of potentially life threatening

embolization. When choosing an agent for initial anticoagulation the Provider should consider the risks of bleeding, patient comorbidities,

preferences, cost, and convenience. The duration of anticoagulation should be individualized according to the presence or absence of

provoking events, risk factors for recurrence and bleeding, and the patient's preferences.

Special populations of patients with acute DVT:

Consider insertion of an IVC filter rather than no therapy for patients:

In whom there is absolute or relative contraindication to therapeutic anticoagulation

Who have recurrent or progressive VTE despite adequate anticoagulation therapy

In whom adequate anticoagulation therapy cannot be achieved/maintained

Before placing an IVC filter, consider adherence to therapy and conditions associated with anticoagulation failure, including cancer,

antiphospholipid syndrome, heparin-induced thrombocytopenia, and vascular compression syndromes (May-Thurner and thoracic

outlet syndrome). If appropriate, consider first escalating the anticoagulation intensity. IVC filters are generally discouraged in cases of

lower extremity DVT, superficial venous thrombophlebitis, VTE older than 1 month, or upper extremity DVT.

When ordering placement of an IVC filter, concurrently schedule a follow up appointment with the PCP (Inpatient Consult to Care

Coordination) to evaluate the necessity, assess anticoagulation risk factors, and consider filter retrieval.

Consider systemic or catheter-directed thrombolytic therapy and/or clot removal (e.g., catheter extraction, catheter fragmentation, surgical

thrombectomy) rather than anticoagulation alone for patients with massive iliofemoral DVT or phlegmasia cerulea dolens with symptoms

for <14 days and good functional status.

Supportive therapies for DVT:

Early ambulation is safe and preferred to bed rest, once the patient is definitively treated.

Elastic graduated compression stockings (GCS) that provide 20 to 30 mmHg of ankle pressure for the prevention of post-thrombotic

syndrome (PTS) may be prescribed, although studies have not shown consistent benefit. If GCS are used, they should be started after

anticoagulant therapy, within two weeks of the diagnosis, and continued for two years. Contraindications to GCS include skin ulceration,

severe arterial insufficiency, allergy to the stocking material, and inability to apply stockings.

Acute Pulmonary Embolism

Hemodynamically stable PE patients:

For those in whom the risk of bleeding is low, anticoagulant therapy is indicated.

For those who have contraindications to anticoagulation, placement of an inferior vena cava (IVC) filter should be considered.

For those in whom the risk of bleeding is moderate or high, therapy should be individualized according to the assessed risk-

benefit ratio and values and preferences of the patient.

For most hemodynamically stable (low risk) patients, thrombolytic therapy is not recommended.

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Those with symptomatic subsegmental PE with 1) low risk of recurrent VTE; 2) adequate cardiopulmonary reserve; and 3) no

evidence of bilateral DVT on Doppler likely do not require anticoagulation.

Hemodynamically unstable PE patients:

Thrombolytic therapy is indicated in most patients, unless there is contraindication.

Embolectomy is appropriate for those in whom thrombolysis is either contraindicated or unsuccessful (surgical or catheter-

based). (See treatment algorithm, page 7.)

Adjunctive therapies for PE:

Therapies that can be added as an adjunct to anticoagulation in patients with PE are:

Supportive medical care with analgesia, intravenous fluids, and oxygen, is appropriate as clinically indicated.

Early ambulation should be encouraged in most patients with acute PE, once the patient is definitively treated. Typically,

ambulation may be limited by the need for postoperative bedrest or by comorbidities including severe symptoms of concurrent

DVT or hypoxia, which can be treated with compression stockings and oxygen, respectively.

Simplified Pulmonary Embolism Severity Index (sPESI)

A prognostic model like PESI may facilitate the decision to treat patients as an outpatient and identify those that require more vigilant

monitoring as an inpatient. The sPESI assigns one point for each of the following variables: age >80 years; a history of cancer; chronic

cardiopulmonary disease; a heart rate ≥110 beats per minute; a systolic blood pressure <100 mmHg; and an arterial oxyhemoglob in

saturation <90 percent. A score of zero indicates a low risk for mortality and severity of complications.

Indications for Consultation and/or Transfer to a Higher Level of Care

PE with large clot burden with respiratory distress requiring mechanical intervention (invasive or non-invasive)

Hemodynamically unstable (tachycardia, dysrhythmias, hypotensive after treatment with IVF)

DVT with rapid propagation/extension or systemic venous obstruction requiring use of thrombolytic therapy

Patient Education and Support

Patient Education

Patient Goal Key Messages for the Patient

Understand VTE.

VTE (blood clots) can happen to anybody at any age and cause serious illness, disability, and even death. VTE can be successfully treated if discovered early.

Symptoms of DVT: About half of people with DVT have no symptoms at all. If you have any of these symptoms, you should see your doctor as soon as possible: o Swelling o Pain o Tenderness o Redness of the skin

Symptoms of PE: You can have a PE without any symptoms of a DVT. If you have any of these signs and symptoms, you should seek medical help immediately: o Difficulty breathing o Faster than normal or irregular heart beat o Chest pain or discomfort, which usually worsens with a deep breath or coughing o Coughing up blood o Very low blood pressure, lightheadedness, or fainting

Other conditions can have signs and symptoms similar to those of DVT and PE. For example, muscle injury, cellulitis (a bacterial skin infection), and inflammation (swelling) of veins that are just under the skin can mimic the signs and symptoms of DVT. Likewise, heart attack and pneumonia can have signs and symptoms similar to those of PE.

Imaging tests can reveal clots in the veins or in the lungs.

Medication is used to prevent and treat DVT. Compression stockings (also called graduated compression

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Patient Education

Patient Goal Key Messages for the Patient

stockings) are sometimes recommended to prevent DVT and relieve pain and swelling. These might need to be worn for 2 years or more after having DVT. In severe cases, the clot might need to be removed surgically.

Immediate medical attention is necessary to treat PE. In cases of severe, life-threatening PE, there are medicines called thrombolytics that can dissolve the clot. Other medicines, called anticoagulants, may be prescribed to prevent more clots from forming.

Some people may need to be on medication long-term to prevent future blood clots.

Take medication as prescribed.

Anticoagulants can have serious side effects and should be taken exactly as directed.

Communicate with your provider.

If a dose is forgotten, the patient should call his/her healthcare Provider or anticoagulation clinician for advice. The dose should not be changed to make up for missed doses, unless the Provider or clinician the patient to do so.

Patients should immediately report to the Pharmacist or Nurse if the pill or tablet looks different from the previous bottle.

If you develop symptoms of DVT or PE (see above), get medical help as soon as possible.

Materials Venous Thromboembolism (Blood Clots) (CDC materials and multimedia)

Lovenox® (Enoxaparin) Patient Instructions: Patients can access this by clicking the link in MyChart.

Prevention

Self-Care Prevention

The following self-care tips can help reduce the risk of DVT:

Move around as soon as possible after having been confined to bed, such as after surgery, illness, or injury.

When sitting for long periods of time, such as when traveling for more than four hours:

o Get up and walk around every 2 to 3 hours.

o Exercise your legs while you’re sitting by:

Raising and lowering your heels while keeping your toes on the floor

Raising and lowering your toes while keeping your heels on the floor

Tightening and releasing your leg muscles

o Wear loose-fitting clothes.

Maintain a healthy weight; avoid a sedentary lifestyle.

Hospital Prevention

For most patients hospitalized with an acute medical illness, who have at least one risk factor for VTE and do not have an increased risk of

bleeding, pharmacologic thromboprophylaxis (rather than mechanical methods or no prophylaxis) is recommended. See CPM: Choosing

an Anticoagulant.

For most patients hospitalized with an acute medical illness with multiple risk factors for VTE, the Provider may consider more aggressive

prophylaxis: either increased intensity of a pharmacologic agent (e.g., three times a day UFH, twice daily enoxaparin), or the addition of a

mechanical device.

For most patients hospitalized with an acute medical illness who have risk factors for VTE and who are at high risk of bleeding or in whom

anticoagulation is contraindicated (e.g., gastrointestinal or intracranial hemorrhage), mechanical methods of VTE prevention (e.g.,

intermittent pneumatic compression, graduated compression stockings, or venous foot pump) are suggested over no prophylaxis.

Special populations of patients require an individualized approach to thromboprophylaxis during an acute hospitalization. These include

patients with heparin-induced thrombocytopenia, patients undergoing neuraxial anaesthesia or analgesia, patients with stroke or cancer,

and patients who are pregnant.

VTE prophylaxis should typically continue until the patient is low risk for VTE or discharged from the hospital.

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Contraindications to Pharmacologic Prophylaxis

Absolute:

Active Hemorrhage

Heparin or enoxaparin use in patients with heparin-

induced thrombocytopenia

Warfarin use in first trimester of pregnancy*

Severe trauma to head, spinal cord or extremities with

hemorrhage within 4 weeks

Placement or removal of indwelling epidural or spinal

catheters

Relative:

Cerebral hemorrhage at any time previously

GI, GU bleed or stroke within past 6 months

Thrombocytopenia (Platelets <100 K/uL)

Coagulopathy (INR>1.5)

Active intracranial lesions/neoplasms

Proliferative retinopathy

Vascular access/biopsy sites inaccessible to hemostatic

control

*An exception is a woman considered to be at especially high risk for thrombosis or thromboembolism (e.g., due to a mechanical heart

valve). In such patients, warfarin use during pregnancy is a potential option; the choice of anticoagulant in this setting is based upon

careful consideration of maternal and fetal risks in discussion with the patient.

Contraindications to Mechanical Prophylaxis

Patient unable to wear due to size or injury

Ischemic Vascular Disease

Care Management

Epic Support Tools

Diagnostic scoring tools accessed using SmartPhrase (e.g., .DVTWELLS, .PEWELLS, .PERC, and .PESI)

The Critical Anticoagulation Flowsheet, available for use by the Anticoagulation Clinic

VTE SnapShot report

Order sets that support the diagnosis or treatment of DVT: PHS GEN DEEP VEIN THROMBOSIS for outpatient Providers;

[1569] ED Dx DVT, [1571] ED Tx DVT, [1547] ED Discharge DVT/PE, in the ED; and [1528] Adult Deep Vein Thrombosis Order

Set in inpatient care settings

Order sets that support the diagnosis or treatment of PE: [1570] ED Dx PE, [1572] ED Tx PE, [1547] ED Discharge DVT/PE, in

the ED; and [1527] Adult Pulmonary Embolism Treatment Order Set in inpatient care settings

SmartSets for discharge: Home Self Mangement (ED); VTE CPG Care Plan (Inpatient)

Epic Tip Sheets for both Ambulatory/Urgent Care and ED

Care Coordination

Care coordination for the patient requiring long-term anticoagulation therapy is described in the clinical approach to

Anticoagulation Management.

Ongoing anticoagulation care is offered to patients and members at the anticoagulation clinics integrated into the Patient-

Centered Medical Home. Anticoagulated patients who require service gap coverage or who do not have a PMG Primary Care

Physician are managed by the Infusion Center. Moreover, the Infusion Center’s pathologists can manage the more clinically

challenging patients.

Before the patient is discharged from the ED, a Patient Navigator schedules the patient for follow up visit with the appropriate

Provider.

A Nurse from the Discharge Call Center follows up with the patient within 24 hours after discharge from the ED or hospital.

Criteria for Home Self Management

No comorbid conditions that require hospitalization

No recent or active bleed; low risk of bleeding

If PE, sPESI score equals 0

No evidence of extension/propagation; no severe systemic venous obstruction

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Creatinine clearance and/or hepatic function appropriate for chosen therapy

Able to self-inject, if parenteral agent is needed

Able to obtain medication in a timely manner

Able to attend follow up appointments

Criteria for Hospital at Home Services

DVT or stable PE

Member of Presbyterian Medicare Advantage, Salud, or Commercial plans

Resides within 25 miles of Presbyterian Hospital (downtown), Rust Medical Center, or Kaseman ED

Measurement and Reporting

CMS requires the documentation of any mechanical intervention or pharmacological intervention ordered by a licensed provider for the

purpose of VTE prophylaxis. This requirement applies to all hospitalized patients (inpatient status) over the age of 18. See VTE

Documentation instructions [PHS login required].

Clinical Definitions

D-dimer A blood test that measures a substance in the blood that is released when a clot breaks up. If the D-dimer test is negative, it means that the patient probably does not have a blood clot.

Doppler Doppler ultrasound is an imaging technology used to detect abnormalities of blood flow. Sound waves are bounced off the blood within a vein. Flowing blood changes the sound waves by the “Doppler effect.” The ultrasound machine can detect these changes and determine whether blood within a vein is flowing normally. Absence of blood flow would confirm the diagnosis of DVT.

inferior vena cava filter (IVC)

An inferior vena cava (IVC) filter is a device that blocks the circulation of clots in the venous bloodstream. It is placed in the inferior vena cava (the large vein leading from the lower body to the heart) with a catheter that is inserted into a vein in the neck or groin and threaded through the blood vessels.

An IVC filter is often recommended in patients with DVT or PE who cannot use anticoagulants because of recent surgery, a stroke caused by bleeding, or significant bleeding in another area of the body. However, IVC filters can be used along with other therapies such as anticoagulation, thrombolysis, or embolectomy when these are appropriate. An IVC filter is also recommended in some patients who develop recurrent PE despite anticoagulation. It may also be recommended for patients whose condition makes them susceptible to life-threatening complications if another PE were to occur. (source)

phlegmasia cerulea dolens (PCD)

An uncommon form of massive proximal (iliofemoral) DVT. For this condition, more aggressive management, usually thrombolysis and/or thrombectomy, may be considered.

venous thromboembolism (VTE)

VTE is the formation of blood clots in the vein. When a clot forms in a deep vein, usually in the leg, it is called a deep vein thrombosis (DVT). If that clot breaks loose and travels to the lungs, it is called a pulmonary embolism (PE). DVT and PE are two manifestations of VTE.

Wells Score

An evidence-based clinical probability assessment to determine the likelihood of VTE. Based on the Wells criteria for DVT, patients can be classified “DVT likely” (Wells Score ≥2.0) and “DVT unlikely” (<2.0). Scores ≥3.0 qualify patient as “High Probability” for DVT. Likewise, patients can be classified “PE likely” (>4.0) and “PE unlikely” (≤4.0). Scores >6.0 qualify patient as “High Probability” for PE. The physician can then choose what further testing is required for diagnosing DVT or PE. (source DVT, source PE)

The scoring model was developed by Phil Wells, MD, MSc, a professor and chief of the Department of Medicine at The University of Ottawa, who researches thromboembolism, thrombophilia and long term bleeding risk in patients on anticoagulants.

PHS | CPM: VTE

© 2018 Presbyterian Healthcare Services | 13

Evidence/Resources

Burnett AE, et al. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis 2016; 41:206–232.

Falck-Ytter Y, et al. Prevention of VTE in Orthopedic Surgery Patients. CHEST 2012; 141(2)(Suppl):e278S–e325S.

Gould MK, et al. Prevention of VTE in Nonorthopedic Surgical Patients. CHEST 2012; 141(2)(Suppl):e227S–e277S

Guyatt GH, et al. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2)(Suppl):7S–47S.

Kahn SR, et al. Prevention of VTE in Nonsurgical Patients. CHEST 2012; 141(2)(Suppl):e195S–e226S.

Kearon C, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST 2016; 149(2):315-352.

Additional References

Related Care Model Topics

Anticoagulation Management

Choosing an Anticoagulant

Discharge Call Center

ED Patient Navigation

Evidence-Based Care Design

Patient-Centered Medical Home (PCMH)

Clinical Practice Guidelines [PHS login required]

Adult VTE Screening and Prophylaxis Orders

Reference Information

Bariatric Center: VTE Prophylaxis Pathway

Fixed Dose Unmonitored Subcutaneous Heparin for

VTE Treatment in Adults: Plan for usage, ordering,

and stocking

Management of Diagnosed Isolated Distal DVT

(algorithm)

Management Plan Following Initiation of Direct Oral

Anticoagulants

Training [PHS login required]

Epic Guide to VTE Prevention Documentation:

Pharmacological vs. Mechanical Intervention

Epic Tip Sheet for Ambulatory/Urgent Care: DVT

Treatment

Epic Tip Sheet for ED: VTE

PCMH: Venous Thromboembolism Management

Policies and Procedures [PHS login required]

Presbyterian Heart Group: Disposition of Patients with

Positive DVT Diagnosis Procedure CAR.PMG.126

Other Resources

Kearon C, Bauer K A. Clinical presentation and

diagnosis of the nonpregnant adult with suspected

deep vein thrombosis of the lower extremity.

UpToDate. 2017 Mar 24; Web.

Lip G YH, Hull R D. Overview of the treatment of lower

extremity deep vein thrombosis (DVT). UpToDate.

2017 Jun 15; Web.

Management of Venous Thromboembolism: Clinical

Guidance from the Anticoagulation Forum

Pai M, Douketis J D. Prevention of venous

thromboembolic disease in acutely ill hospitalized

medical adults. UpToDate. 2017 Jul 20; Web.

Tapson V F. Treatment, prognosis, and follow-up of

acute pulmonary embolism in adults. UpToDate. 2017

Apr 06; Web.

Taylor Thompson B, Kabrhel C, Pena C. Clinical

presentation, evaluation, and diagnosis of the

nonpregnant adult with suspected acute pulmonary

embolism. UpToDate. 2017 Sep 13; Web.

Taylor Thompson B, Kabrhel C. Overview of acute

pulmonary embolism in adults. UpToDate. 2016 Dec

16; Web.

World Thrombosis Day